Application for Hassle-free Hospital Admission          Plan features 
Entry age: 4 weeks to 60 years (Renewable to Age 70)  All information entered is strictly kept confidential.
Children (Dependants) 2 weeks up to 23 years of age.
Type of  Hospitalization Need EC100      EC150      EC200      EC250      EC300     EC350
Coverage for :
Full name of Proposer:
Proposer's gender:
Race:
Marital status:
Height ( ft & in or cm ):
Weight ( lbs & oz or kg ):
Proposer's Date of Birth: Day    Month    Year
IC No: New IC:       Old IC:
Residence Address:
Office Address:
Health condition:
Proposer's Occupation:
Spouse's Occupation :
Spouse's Date of Birth : Day    Month    Year
Other particulars (if any):

Contact tel. number:
Best time to call you:
Email address:
Person to contact:

Our representative will call you, as soon as we receive your proposal, .  Thanks and have a nice day!

 

If you have any query, please use our  Enquiry  form,  E-mail  us  or call  012-5158027